The Facial Platysma and Its Underappreciated Role in Lower

Home , Mentalis, Platysma muscle, Risorius

rohibited. orange ’ Department of † whereas injections into the 3 2 c muscles alone or several fi have been underappreciated. MA can alter the shape ofmuscle the thickness jawline and by bulk. reducing The use of botulinum toxin A (BoNT-A)is in considered this as region an advanced techniqueacceptance and after gained years of experience inAs the upper with face. the upper facial areas,the it treatment can of be speci indicated for muscles combined as a whole lowerUsually, face to complex. address mouth frown andfolds melomental (Marionette Lines), the depressor anguliinjected. oris Mentalis is is the target whenalleviating correcting a or mental crease and/or aappearance peau over d the chin, DOI: 10.1097/DSS.0000000000001135 · 1049 – Such changes can be 1 † Dermatol Surg 2017;43:1042 · pars facialis, mandibularis, and modiolaris ed by neuromodulators, either alone or in fi he muscular anatomy involved in themuscles lower of face facial expression is complex and llers, resurfacing with laser and energy-based devices, combination with other treatment modalities (e.g., fi surgery). modi *Dermatologic Clinic, Hospital do Servidor Público Municipal de São Paulo, São© Paulo, 2017 Brazil; by theISSN: American 1076-0512 Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved. T CONCLUSION Thethat upper can platysma be muscle modulated plays safely a with relevant neuromodulators. A.R.T. role de in Almeida has the been functionaland a anatomy consultant Galderma. to of A. Allergan the Inc. Romitiresearch lower and has Merz, by face been and Allergan, participated paid in Inc.,Inc., to clinical Medicis, Medicis, trials give for Inc., Inc., lectures Allergan Ipsen Ipsen for Pharma, Galderma. Pharma, Merz J.D.A. Merz GmbH, Carruthers GmbH, and has and Solstice been has Neurosciences. paid been to a do consultant to Allergan, RESULTS Alateral total enhancement of of 161 lowermandibular patients facial have border, contour, been and relaxation treatedmental lower of in folds. high the deep last horizontal vertical 2 lines smile years located with lines just the below present following the lateral results: lateral frontal to and the oral commissures and melo- bands, horizontal lines, and lossHowever, of its lower face contour are effectively treated withOBJECTIVE botulinum toxin A (BoNT-A). Todynamics demonstrate and the contour. role of BoNT-A treatment of theMATERIAL upper AND platysma METHODS and itsfacial impact platysma on components, Retrospective lower aiming analysis face to ofinjections block cases the into treated lower the by face an mentalis asand injection muscle a pattern whole below and encompassing complex. 2 It the the horizontal consistedduring of mandible lines motion 2 of (frontal intramuscular (total BoNT-A and dose, injections oblique superficially 16 views), performed before onabotulinumtoxinA above and U/side). after Photographs treatment. were taken at rest and BACKGROUND The platysma is a superficial muscle involved in important features of the aging neck. Vertical The Facial Platysma and ItsLower Underappreciated Face Role Dynamics in and Contour Ada R.T. de Almeida,FRCSC, MD,* FRC Alessandra (OPHTH) Romiti, MD,* and Jean D.A. Carruthers, MD, (R), masseter (MA), mentalis (M), andmuscles. platysma It (P) is known that notcontractions only wrinkle persistent the skin, but theplatysmal increased resting tone is also implicatedmuscular in role the of senescence. includes the orbicularis oris (OO), depressororis angulis (DAO), depressor labii inferioris (DLI), risorius Ophthalmology and Visual Science, University of British Columbia, Vancouver, British Columbia, Canada © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is p 1042

Downloaded from https://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FlQBFFqx6X8f2YacK2KomzwZi55X7VWV75FoKYjzDDE= on 03/01/2019 Downloaded from https://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FlQBFFqx6X8f2YacK2KomzwZi55X7VWV75FoKYjzDDE= on 03/01/2019 DE ALMEIDA ET AL

Figure 1. Cadaver dissection showing the depressor angulis oris, and platysma pars mandibularis (left). The latter, when contracted, produces high parallel lines and wrinkles located just below the lateral mandibular border (right).

The platysma is a broad flat muscle that covers the were horizontally injected along each mandible and anterior and lateral aspects of the neck. It rises from into the upper portion of the posterior platysmal the superficial fascia over the upper chest and ascends band.11,12 The result was a visible release of the superior-medially from the neck to insert into 3 points: platysma muscle’sdownwardpullingandjawline medially into the mentum; centrally into the perios- recontouring. teum of the ramus of the mandible; and laterally to the OO, DAO, and R muscles overlying subcutaneous On the other hand, whereas useful when adequately tissue.4 Its anterior fibers from both sides may cross indicated, the Nefertiti Lift technique does not address each other at the midline, forming various patterns of the anterior platysma fibers. Because only the lateral decussation, whereas complete separation may also upper half and the posterior platysma band are trea- occur.5,6 When the upper and lower portions of the ted, the untreated anterior fibers may be recruited platysma contract, they pull the skin to the center of during neck contraction, resulting in local wrinkling, the muscle like a compressed accordion, forming banding worsening, and loss of anterior facial con- horizontal neck lines. tour. To avoid these problems, many BoNT-A experts use their own technical variations of the method, Most BoNT-A injection techniques have targeted the adapted to each patient’s individual needs. platysmal bands and horizontal necklines (like “laces”). First described by Brandt and Bellman, not Some described techniques are a single injection only the tightening of the neck, but also some kind of sequence performed horizontally at 3 to 4 sites at the jawline recontouring was noticed by these authors.7 mandibular line (Dr. A. Romiti, MD, personal com- To achieve the results, though, high doses of BoNT-As munication, June 6, 2013), a technique using a single were needed (up to 200 units of onabotulinumtox- injection site with 20U to 30U onabotulinumtoxinA inA), and side effects related to the toxin diffusion to per side,13 or an entire neck treatment of minute adjacent muscles were also reported. This fact made intradermal doses of BoNT-A, with a total dose of 60 experts recommend reducing the total dosage used, to to 80 onabotulinumtoxinA U (Dr. Woffles Wu avoid complications.8–10 Microbotox technique).14

Focusing speciﬁcally on jawline redeﬁnition, Levy The objective of this article is to review the functional described the “Nefertiti lift,” where individuals anatomy and to evaluate the role of BoNT-A

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treatment of the upper platysma muscle and its impact lateral to the DAO. Its contraction contributes to the on the lower facial dynamics and contour. appearance of lower vertical deep smile lines located laterally to the oral commissures and laterally to the melomental folds.15 (Figure 3). Upper Platysma Functional Anatomy

Although appearing in face and neck drawings in Material and Methods anatomic papers, especially about botulinum toxin, the upper platysma location and function are fre- Study Design quently neglected or forgotten. It is classically described as having 3 parts: This is a retrospective, open label study performed at 3 centers, which complied with the ethical rules of the Platysma pars mandibularis, which inserts onto the 2000 Declaration of Helsinki. To achieve complete lower border of mandible and onto the skin and sub- relaxation of the upper platysma area, the entire lower cutaneous plane of the lower face, with some ﬁbers face was considered as a single region and treated as interdigitating with the DAO. Its contraction forms a “lower face complex.” For this reason, a standard oblique and horizontal parallel lines and wrinkles that injection pattern was chosen and applied for all subjects. appear high in the neck just below the lateral mandibular border and above the necklace lines (Figure 1). Patient Selection and Documentation

Platysma pars labialis, which travels deep to DAO, re- Patients aged 18 years and older, seen at the Derma- emerges medially to it, interdigitates and blends to tologic Clinic of Hospital do Servidor Público OO, DLI, and mentalis muscles, and in some cases, Municipal de São Paulo and the private clinics of the occupies the space between DLI and DAO. Its con- first 2 authors, were selected. Subjects were invited to traction may be related to horizontal lines located participate if they had investigator identified, loss of below the oral commissures and lower lip (Figure 2). lower face contour, and/or lower face and upper neck wrinkles and lines, during lower face animation. Platysma pars modiolaris, which includes all of the Upper neck was defined as the region located just remaining fibers of upper platysma that are postero- below the mandibular border. There were no

Figure 2. Cadaver dissection showing the depressor angulis oris, depressor labii inferioris, platysma pars labialis, and its intimate relationship (left). Contraction of pars labialis may be related to horizontal lines located below the oral commissures and inferior lip (right).

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physician and the treated subject only at the follow-up visit, after 2 to 4 weeks. The analysis was standardized as follows: For each photograph pair, improvement of lower face contour was observed and compared. For efficacy measures, subjects were asked if, during animation, the lower face contour appeared more defined in lateral view (yes or no) and/or changed (more linear/ triangular than round, irregular) in frontal view. Treated subjects were also asked if they were satisfied and willing to repeat the treatment (yes or no). At that moment, touch-ups could be performed if needed.

Treatment Technique

Botulinum toxin A vials were reconstituted as follows: 2 mL of normal saline solution were added to 100U vials (Botox/Xeomin) for a ﬁnal concentration of 50 U/ mL, whereas 3.2 mL were added to 500U Dysport vials to reach a ratio of 1:3 with the other neuromodulators.

To treat the lower face as a whole unit, 2 sites of the mentalis muscle were intramuscularly injected, fol- Figure 3. Cadaver dissection showing the platysma pars lowed by superficial BoNT-A injections in a pattern modiolaris which fibers are posterolateral to the depressor angulis oris (left). Its contraction contributes to the consisting of 2 horizontal lines in each side of the lower appearance of lower vertical deep smile lines located lat- face. The first one was injected into 3 injection sites eral to the oral commissures and lateral to melomental with 2U each, at the mandibular border, starting at the folds (right). DAO level and spaced every 2 cm laterally, ending at restrictions regarding sex or cutaneous phototype. the mandibular angle. The second horizontal line was Patients were ineligible if they had received neuro- placed 2 cm below the mandibular border, starting at modulator treatments in the preceding 120 days or if a site below and between the mentalis and DAO they were planning in the upcoming month to have any muscles, spaced every 2 cm, running laterally to procedure to improve lower face contour, including a point after the mandibular angle, laying between the fillers, chemical lipolysis injections, and energy-based above ones (Figure 4). devices and/or surgeries. Interested patients provided written informed consent. This second line was treated with 2U each into 4 injection sites. The first 2 sites might be injected with Photographs were taken at rest, during full smile, and higher doses (2.5U–3U) in selected individuals who while contracting the lower face (upon request to say show a stronger platysmal band for a total dosage of “eeeeee”) in frontal and oblique views before injection 14U to 18U BoNT-A per side. Every injected site was and after treatment, scheduled to occur after at least 15 compressed for a few minutes right after withdrawing and no more than 30 days, keeping the same camera, the needle to reduce the likelihood of bruising. lighting, and distance parameters.

Results Patients were instructed to report any side effects, heaviness sensation, or asymmetries that might occur. A total of 161 patients, both men and women, were The photograph pairs were evaluated by the injecting included. Table 1 shows detailed demographic patient

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Figure 4. The injection pattern (left) and its corresponding location in the cadaver (right).

characteristics. Most individuals received 16U per side The second finding was relaxation, and in some cases, (including 2U into the mentalis muscle). complete disappearance of several oblique and horizontal parallel lines and wrinkles, which were seen just When comparing before and after photographs dur- below the lateral mandibular border during platysmal ing animation, the effects could be observed in all contraction. In some patients, these wrinkles may patients at the follow-up visit.Physicians andsubjects reach the lower face and are difficult to treat (Figure 6). were all satisfied with the treatment, and patients confirmed the will to repeat the technique in the The third and most surprising effect was relaxation, future. and in some cases, effacement of the lower vertical deep smiles lines, located just behind the oral com- Three findings showing improvement could be missures (Figures 5 and 6). observed. The first sign was enhancement of lower facial contour, particularly during lower facial mus- Since improvement of lower face contour, and not cular contraction. The skin under the mandibular effacement of rhytides, was the purpose of our study, border seemed more closely apposed to the bone comparative facial wrinkles scales were not included structure, and this effect could be noticed in lateral and in the evaluation. in frontal views. Previously loose skin and the round shape of the lower face were replaced by a more linear Regarding adverse effects, 1 patient described (in some subjects, more triangular) and better defined a heaviness sensation after treatment, while in 2 oth- contour. Some patients reported that their face looked ers, a very mild unilateral reduction in the lower lip “thinner” in frontal view as if they had lost weight retraction was observed, probably because of slight (Figure 5). weakness of the DLI. However, the latter was not perceived by the patients and did not require any correction. No complaints of dysphagia or voice TABLE 1. Demographic Characteristics of alteration were noted. Treated Subjects

Age Discussion Range 28–73 Mean 56.5 The full role of the upper platysma muscle in the lower Median 57.5 face is still poorly understood and explored. Never- Gender theless, attentive observation may show that it can be Female 142 very active in some patients, particularly with Male 19 Botulinum toxin A senescence. OnabotulinumtoxinA 131 IncobotulinumtoxinA 19 Although Benedetto15 described in detail its anatomic AbobotulinumtoxinA 11 boundaries, the consequences of its contraction on the Dose/side skin is still a complex issue because of its intimate Mentalis (M)/platysma 2U/14U relationship, interdigitation, and blending with other

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Figure 5. Fifty-year-old lady before and after the facial platysma botulinum toxin A treatment in oblique (left) and frontal views (right). Note the sharper, better deﬁned lower facial contour with a more linear shape and effacement of lower face wrinkles (red circle).

lower facial muscles. During contraction, muscles with DAO, OO, DLI and Mentalis, its contraction follow force vectors that generally run from their may be related to the appearance of horizontal lines in insertion (mobile portion of the muscle) to their origin the lower face—below the oral commissures—that can (fixed portion of the muscle), determining hyperki- be identifiable even in young individuals (Figure 2). netic lines perpendicular to the contraction’s direction and resulting in horizontal, vertical, and/or oblique And last, but not less important, the upper platysma wrinkles.16 Therefore, the horizontal lines that appear pars modiolaris is frequently forgotten in the facial below the mandible and the chin may be secondary to motion. It includes all the remaining fibers of the facial the contraction of the pars mandibularis of the upper platysma that are posterolateral to the DAO. Con- platysma, since it inserts onto the lower border of the traction of these horizontally oriented fibers pulls the mandible as well as in the skin and subcutaneous plane corner of the mouth laterally, thereby forming vertical of the lower face, with some fibers interdigitating with lines and wrinkles located behind the DAO. In some DAO (Figure 1). patients, it has considerable dermal insertions lateral to the modiolus parallel to the NLF. In these cases, On the other hand, as the pars labialis is considered a smile or grimace produces lateral creases in the skin, a direct labial depressor, interdigitating and blending which may be difficult to treat (Figure 3).5

Figure 6. Thirty-eight-year-old male patient. Before (above) and after upper platysma botulinum toxin A treatment (below). Note the amelioration of oblique and horizontal parallel lines located below the lateral mandibular border and lower face deep vertical smile lines (red circle).

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The idea is that the upper platysma region behaves like mandibular border. If necessary (a strong platysmal awholeunitandhasadiversefunctionthanitslower band in one side), higher amounts of BoNT-A can be part. Because it is a very superficial muscle, deep BoNT- placed below the mandible in the first 2 sites of the sec- Ainjectionsarenotrecommended, to avoid affecting ond injection line, to prevent or minimize lip asymme- underlying muscles of deglutition and causing dysphagia tries or reduction in the extent of the smile due to and voice alterations.17 The described technique, using diffusion to R muscle (Risorius smile). Although not superficial horizontal injections,aimstorelaxitsentire observed in the authors’ cases, recruitment of lower width, leaving fewer areas without treatment when platysma fibers may occur. If necessary, it can be cor- compared with the technique where only the vertical rected at the follow-up visit after 2 to 4 weeks, with bands were addressed. It will allow enhancement of additional BoNT-A doses to the corresponding location. lower facial contour in profile as well as in frontal view, in repose and during motion. Here, it differs from the Limitations of this study are its retrospective nature, the Nefertiti lift because the Nefertiti lift technique addresses lack of comparative facial wrinkles scales before and only the posterior fibers of the upper platysma, but not its after treatment that could estimate more accurately the anterior portion at the cervicomental junction, improv- impact on deep smile lines and submandibular lines, ing the mandibular contour mostly in lateral views. and the combined blockage of some lower face muscles such as DAO and mentalis. A prospective trial in the The botulinum toxin denervation of the anterior por- near future may be useful for this purpose. tion of the platysma muscle, though, can produce a gentle anterior neck lift.2 Some individuals treated by The upper platysma muscle plays a relevant role in the the new technique, even when noticing the enhance- functional anatomy of the lower face, acting as a major ment of the lateral mandibular contour, reported that depressor that can be modulated by neuromodulators. their lower face looked thinner in frontal view. More- When addressed in combination with other lower over, amelioration of horizontal wrinkles located at and facial muscles as a whole complex, enhancement of below the mandibular line and chin was also observed. lower facial contour and relaxation of dynamic The same effect could be noticed with deep vertical wrinkles of the lower face will be achieved. smile lines that arose near the mandibular border. Acknowledgments The authors thank Dr. Hee-Jin Most patients received concomitant BoNT-A treat- Kim, DDS, PhD. Professor, Division in Anatomy and ment in the upper face. In the lower face, the total dose, Developmental Biology, Department of Oral including into the mentalis muscle, was lower than Biology, Yonsei University College of Dentistry, 20U per side, with most patients being treated with Seoul Korea, for the anatomical sample of Figure 2. only 16U per side. For this reason, no sensations of heaviness during motion of the lower face were References

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12. Levy P. Neurotoxins: current concepts in cosmetic use on the face and Address correspondence andreprintrequeststo:Ada neck-jawline contouring/platysma bands/necklace lines. Plast Reconstr R.T. de Almeida, MD, Dermatologic Clinic, Hospital do Surg 2015;136:80S–83S. Servidor Público Municipal de São Paulo, Rua Turiassu, 13. Carruthers J, Trindade de Almeida AR. Platysma and Nefertiti lift. In: 390, cjs 113/114, Perdizes São Paulo, SP, Brazil 05001- Carruthers J, Carruthers A, editors. Procedures in Cosmetic 000, or e-mail: [email protected]

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